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This study investigated the factors associated with serious maternal morbidity (SMM) in women seen at public maternity hospitals in Ribeirão Preto, São Paulo State, Brazil. This was a cross-section analytical quantitative study. Participation included 1,098 postpartum women who had given birth at one of the four maternity hospitals in the municipality. Data were collected from August 3, 2015, to February 2, 2016, using face-to-face interviews and data obtained from patient records and prenatal cards. The dependent variable for data analysis was the serious maternal morbidity, that is, when the woman was classified as maternal near miss or potentially life-threatening condition based on WHO eligibility criteria. The study calculated the maternal near miss ratio, odds ratio (OR), 95% confidence interval (95%CI), and multiple logistic regression. The maternal near miss ratio was 3.6 cases per 1,000 live births. Complications occurred mainly during pregnancy (53.8%), and hypertensive disorders were the most frequent (49.4%). Multiple regression analysis showed an association between serious maternal morbidity and high-risk pregnancy (OR = 4.5, 95%CI: 2.7-7.7) and induced labor (OR = 2.1, 95%CI: 1.2-3.9). The occurrence of serious maternal morbidity mainly during pregnancy, featuring hypertensive syndromes, points to the need for better screening and management of high blood pressure in the prenatal period. The association between serious maternal morbidity and high-risk pregnancy also calls attention to prenatal care, for the demand for greater care for women classified as having gestational risk. Quality of care is a key point for dealing with maternal morbidity and mortality in Brazil.Este estudo investigou os fatores associados à morbidade materna grave entre mulheres atendidas em maternidades públicas do Município de Ribeirão Preto, São Paulo, Brasil. Trata-se de um estudo quantitativo, analítico, transversal. Participaram 1.098 puérperas com parto em uma das quatro maternidades públicas do município. A coleta de dados ocorreu entre 3 de agosto de 2015 e 2 de fevereiro de 2016, a partir de entrevistas face a face, obtenção de informações dos prontuários e dos cartões da gestante. Para a análise de dados, considerou-se como variável dependente a ocorrência de morbidade materna grave, ou seja, quando a mulher era classificada como near miss materno ou condição potencialmente ameaçadora à vida a partir dos critérios de elegibilidade da Organização Mundial de Saúde. Calculou-se a razão do near miss materno, odds ratio (OR), intervalo de 95% de confiança (IC95%) e regressão logística múltipla. A razão do near miss materno foi de 3,6 casos por mil nascidos vivos. As complicações ocorreram principalmente na gravidez (53,8%) e os distúrbios hipertensivos foram os mais frequentes (49,4%). A análise de regressão múltipla mostrou associação entre morbidade materna grave e gestação de risco (OR = 4,5; IC95%: 2,7-7,7) e com trabalho de parto induzido (OR = 2,1; IC95%: 1,2-3,9). A ocorrência de morbidade materna grave, principalmente na gestação, com destaque para as síndromes hipertensivas, aponta para a necessidade de melhor rastreamento e manejo da elevação dos níveis pressóricos no pré-natal. A associação entre morbidade materna grave e gestação de risco também remonta ao pré-natal, para a demanda de uma maior atenção às mulheres classificadas como risco gestacional. A qualidade da assistência é ponto chave para o enfretamento da morbimortalidade materna no país.Este estudio investigó los factores asociados a la morbilidad materna grave entre mujeres atendidas en maternidades públicas del municipio de Ribeirão Preto, São Paulo, Brasil. Se trata de un estudio cuantitativo, analítico, transversal. Participaron 1.098 puérperas con parto en una de las cuatro maternidades públicas del municipio. La recogida de datos se produjo entre el 3 de agosto de 2015 al 2 de febrero de 2016, mediante entrevistas cara a cara, obtención de información de los historiales y cartillas de las gestantes. Para el análisis de datos, se consideró como variable dependiente la ocurrencia de morbilidad materna grave, o sea, cuando la mujer era clasificada como near miss materno o condición potencialmente amenazadora para la vida, a partir de los criterios de elegibilidad de la Organización Mundial de Salud. Se calculó la razón del near miss materno, odds ratio (OR), intervalo de 95% de confianza (IC95%) y regresión logística múltiple. La razón de near miss materno fue de 3,6 casos por 1.000 nacidos vivos. Las complicaciones se produjeron principalmente en el embarazo (53,8%) y las alteraciones hipertensivas fueron las más frecuentes (49,4%). El análisis de regresión múltiple mostró asociación entre morbilidad materna grave y gestación de riesgo (OR = 4,5; IC95%: 2,7-7,7) y con trabajo de parto inducido (OR = 2,1; IC95%: 1,2-3,9). La ocurrencia de morbilidad materna grave, principalmente en la gestación, resaltando los síndromes hipertensivos, apunta la necesidad de un mejor rastreo y gestión de la elevación de los niveles presión arterial en el período prenatal. La asociación entre morbilidad materna grave y gestación de riesgo también se remonta al período prenatal, con el fin de que se preste una mayor atención a las mujeres clasificadas como de riesgo gestacional. La calidad de la asistencia es un punto clave para combatir la morbimortalidad materna en el país.

Background The partner has an important role when he participates of the prenatal care as showed in the positive results relate to the mother and the child health. For this reason it is an important strategy to bring future fathers closer to health services and to improve their link with paternity. Aim To evaluate whether the implementation of SMS technology, through the PRENACEL program for the partner as a health education program, is a useful supplement to the standard prenatal monitoring. Methods A parallel cluster randomized trial was carried out, with the clusters representing primary care health units. The 20 health units with the largest number of pregnant women in 2013 were selected for the study. There was a balance of the health units according to the size of the affiliated population and the vulnerability situation and these were allocated in intervention and control health units by the randomization. The partners of the pregnant women who started prenatal care prior to the 20th week of gestation were the study population of the intervention group. The participants received periodic short text messages via mobile phone with information about the pregnancy and birth. In the control group units the partners, together with the women, received the standard prenatal care. Results One hundred eighty-six partners were interviewed, 62 from the PRENACEL group, 73 from the intervention group that did not opt ​​for PRENACEL and 51 from the control group. A profile with a mean age of 30 years was found and the majority of respondents (51.3%) declared themselves as brown race/color. The interviewees presented a mean of 9.3 years of study. The majority of the men (95.2%) cohabited with their partner and 63.7% were classified as socioeconomic class C. The adherence to the PRENACEL program was 53.4%. In relation to the individual results, there was a greater participation of the PRENACEL partners in the prenatal consultations, as well as a greater presence of them accompanying the woman at the moment of the childbirth when compared to the other groups. Conclusion The study showed that a health education strategy using communication technology seems to be a useful prenatal care supplement; the intervention had a good acceptability and has a promising role in men’s involvement in prenatal, labour and postpartum care of their partners. Trial registration Clinical trial registry: RBR-54zf73, U1111–1163-7761.

This study analyzed the occurrence of severe maternal morbidity, the most frequent diagnostic criteria, and the quality of obstetric care in public hospitals in Ribeirão Preto, São Paulo State, Brazil. A quantitative surveillance survey of severe maternal morbidity used World Health Organization (WHO) criteria for potentially life-threatening conditions and maternal near miss. Cases were identified from August 1, 2015, to February 2, 2016. The sample included 259 women with severe maternal morbidity (potentially life-threatening conditions/maternal near miss) during the gestational and postpartum cycle, hospitalized for childbirth in the four public institutions providing obstetric care in the city. The descriptive analysis was based on absolute and relative rates of diagnostic criteria for potentially life-threatening conditions and maternal near miss, besides description of the women in the sample (sociodemographic characteristics, obstetric history, and prenatal and childbirth care). Quality of care indicators set by the WHO based on morbimortality were also calculated. There were 3,497 deliveries, 3,502 live births in all the hospitals in the city, two maternal deaths, and 19 maternal near miss. Maternal near miss ratio was 5.4 cases per 1,000 live births, and the maternal mortality ratio was 57.1 deaths per 100,000 live birth. The mortality rate among cases with severe maternal outcome (maternal near miss plus maternal death) was 9.5%. The study revealed important potentially life-threatening conditions and maternal near miss rates. The occurrence of deaths from hemorrhagic causes highlights the need to improve the quality of obstetric care. The findings can potentially help improve local policy for obstetric care.

AimTo evaluate prenatal care knowledge of Brazilian community health workers (CHWs).BackgroundRoutine prenatal care is critical for reducing health risks in women and their children. One of the responsibilities of primary healthcare providers is the provision of prenatal care. The CHWs, with their frequent contact with populations, work to improve health outreach efforts and therefore may be key role players in prenatal care.MethodsThis was a cross-sectional study. A questionnaire was developed to ascertain the degree of knowledge regarding prenatal care of CHWs, including: (1) general responsibilities of CHWs; (2) the initial contact with a pregnant woman; (3) examinations and vaccinations recommended for pregnant women; (4) pregnancy complications and signs of labor; and (5) lifestyle considerations for pregnant women. Responses were categorized into levels for knowledge. Demographic data were also collected. Descriptive analyses were conducted. Proportions of subjects with different levels of knowledge were compared according to each demographic variable, separately for each block of knowledge, using the χ2 and Fisher’s exact tests.FindingsIn total, 194 CHWs were interviewed. Overall, the majority of the CHWs presented high levels of knowledge in blocks 1 (43%), 2 (59%) and 5 (83%). However, in block 3 the proportions of subjects with high levels of knowledge regarding examinations and vaccinations were 35 and 40%, respectively. Only 24% of the participants presented a high level of knowledge in block 4. Stratified data analyses suggest that females were statistically more likely to have high levels of knowledge, whereas no statistically significant differences were found for the other demographic variables. Health services are already routinely using the questionnaire.ConclusionThe results suggest that CHWs, especially female CHWs, have an important role in assisting pregnant women in the community. The study indicates the areas of knowledge that require more specific attention from training providers.

PRENACEL is a study that incorporates two innovative approaches to maternal and perinatal health: the need to improve women's level of satisfaction with the birthing experience and an assessment of the impacts of information and communication technologies in health. The approaches involve a communication program via short cellphone text messages, developed for Brazilian pregnant women in prenatal care in the Brazilian Unified National Health System. The analysis aims to determine whether the program contributes positively to women's perceived preparedness for childbirth. A randomized cluster trial was performed in 20 primary care units in Ribeirão Preto, São Paulo State, in 2015 and 2016. Data were collected for 1,210 women from interviews and patient charts. The data were submitted to two analytical models, per protocol and intention-to-treat. Women that had received information from the PRENACEL program during pregnancy were more likely to feel prepared for labor and delivery and to feel that prenatal care had helped them feel more prepared. There were also positive impacts on bonding with the newborn and breastfeeding in the delivery room and on knowledge of obstetric interventions. No differences were seen in the other maternal and perinatal outcomes, including women's satisfaction with the birthing care. PRENACEL can help expand women's access to strategic information for them to feel better prepared for the birthing experience.O PRENACEL é uma pesquisa que incorpora duas abordagens inovadoras para a saúde materna e perinatal: a necessidade de melhorar os níveis de satisfação das mulheres com a experiência do parto; e, a avaliação de impactos do uso de tecnologias de informação e comunicação em saúde. Trata-se de um programa de comunicação via mensagens curtas de textos no celular desenvolvido para gestantes brasileiras atendidas no pré-natal do Sistema Único de Saúde. Nesta análise, pretende-se determinar se o programa contribui positivamente para a percepção das mulheres de sentirem-se melhor preparadas para o parto. Um ensaio aleatorizado por conglomerados foi realizado em 20 unidades de saúde da atenção primária de Ribeirão Preto, São Paulo, entre 2015 e 2016. Dados de entrevista e revisão de prontuários foram coletados de 1210 mulheres. Estes foram submetidos a dois modelos de análise, por protocolo e intenção de tratamento. Receber informações do programa PRENACEL durante a gestação foi associado a um aumento na percepção das mulheres de se sentirem melhor preparadas para o parto, e na percepção de que o pré-natal colabora para que se sintam mais preparadas. Também foram observados impactos positivos no estabelecimento do contato pele a pele e aleitamento materno em sala de parto e no conhecimento sobre intervenções obstétricas. Não foram encontradas diferenças nos demais desfechos maternos e perinatais avaliados, incluindo a satisfação das mulheres com o atendimento ao parto. O PRENACEL pode contribuir com a ampliação do acesso das mulheres a informações que lhes sejam estratégicas para que se sintam mais bem preparadas para a experiência do parto.PRENACEL es una investigación que incorpora dos abordajes innovadores para la salud materna y perinatal: la necesidad de mejorar los niveles de satisfacción de las mujeres que han vivido la experiencia de un parto; además de la evaluación de los impactos del uso de tecnologías de la información y comunicación en salud. Se trata de un programa de comunicación vía mensajes cortos de texto en el móvil, desarrollado para gestantes brasileñas atendidas en el servicio prenatal del Sistema Único de Salud. En este análisis se pretende determinar si el programa contribuye positivamente a la percepción de las mujeres respecto a sentirse mejor preparadas para el parto. Se realizó un ensayo aleatorizado por conglomerados en 20 unidades de salud de atención primaria en Ribeirão Preto, São Paulo, entre 2015 y 2016. Los datos de entrevista y revisión de registros médicos se recogieron con 1.210 mujeres. Estos se sometieron a dos modelos de análisis, por protocolo e intención de tratamiento. Recibir información del programa PRENACEL durante la gestación se asoció a un aumento de la percepción de las mujeres en cuanto a sentirse mejor preparadas para el parto, y desde la percepción de que el periodo prenatal presta apoyo para que se sientan más preparadas. También se observaron impactos positivos en el establecimiento del contacto piel con piel, lactancia materna en sala de parto, y en el conocimiento sobre intervenciones obstétricas. No se observaron diferencias en los demás desenlaces maternos y perinatales evaluados, incluyendo la satisfacción de las mujeres con la atención durante el parto. PRENACEL puede contribuir a la ampliación del acceso de las mujeres a información que les resulte estratégica para que se sientan mejor preparadas durante la experiencia del parto.

This study aimed to identify the treatment itineraries of Brazilian women with severe maternal morbidity. This was a qualitative, descriptive, exploratory study in a university referral hospital for high-risk pregnancy in the interior of São Paulo State, Brazil. The sample included 16 women with severe complications during pregnancy, childbirth, or postpartum. Data were collected with semi-structured, taped, transcribed interviews subsequently submitted to Content Analysis. The results showed that at the onset of illness, the women take various paths to reach low and high-complexity services, while also relying on neighbor women, pharmacies, and self-medication. They encounter obstacles in the services' receptiveness, continuity of care, case-resolution capacity, and referrals within the healthcare network. Critical points were observed in obstetric care: women are frequently subjected to trekking from one health service to another to obtain care, delays in referrals, and institutional violence. The tertiary hospital was described as receptive and effective. The study identified problems in the entire chain of obstetric care, helping explain how the healthcare system is organized to deal with severe maternal complications.Este estudo objetivou identificar os itinerários terapêuticos de mulheres acometidas por morbidade materna grave. Trata-se de pesquisa qualitativa, descritiva e exploratória realizada em um hospital universitário de referência em gestação de alto risco do interior do Estado de São Paulo, Brasil. Participaram 16 mulheres com complicações graves na gestação, parto ou pós-parto. Os dados foram coletados por entrevistas semiestruturadas, gravadas, transcritas e analisadas mediante Análise de Conteúdo. Os resultados mostram que as mulheres, ao iniciarem o processo de adoecimento, seguem trajetórias diversas, buscando serviços da baixa e alta complexidade, procurando também por vizinha, farmácia e uso de automedicação. Destacam-se entraves referentes ao acolhimento, continuidade do cuidado, resolutividade e referência na rede de atenção à saúde. Observaram-se importantes pontos críticos em relação à assistência obstétrica, sendo a peregrinação por serviços de saúde, a demora do encaminhamento e a violência institucional, realidades vivenciadas pelas mulheres. O serviço terciário foi apontado como acolhedor e eficaz no atendimento. Este estudo permitiu a identificação dos problemas que existem em toda a cadeia de cuidados obstétricos, e tal conhecimento permite o entendimento de como o sistema de saúde se organiza em relação ao atendimento das mulheres com complicações maternas graves.Este estudio tuvo por objetivo identificar los itinerarios terapéuticos de mujeres afectadas por morbilidad materna grave. Se trata de una investigación cualitativa, descriptiva y exploratoria, realizada en un hospital universitario de referencia en gestación de alto riesgo del interior del Estado de São Paulo, Brasil. Participaron 16 mujeres con complicaciones graves durante la gestación, parto o posparto. Los datos fueron recogidos gracias a entrevistas semiestructuradas, grabadas, transcritas y analizadas mediante Análisis de Contenido. Los resultados muestran que las mujeres, al comenzar el proceso de padecimiento, siguen trayectorias diversas, buscando servicios de baja y alta complejidad, recurriendo también a vecinas, farmacias y a la automedicación. Se destacan trabas en relación con la acogida, continuidad del cuidado, resolutividad y referentes a la red de atención a la salud. Se observaron importantes puntos críticos, respecto a la asistencia obstétrica, siendo la peregrinación por servicios de salud, la tardanza en la derivación a especialistas y la violencia institucional, realidades vividas por las mujeres. El servicio terciario fue descrito como acogedor y eficaz en la atención. Este estudio permitió la identificación de los problemas que existen en toda la cadena de cuidados obstétricos, y este conocimiento permite el entendimiento de cómo el sistema de salud se organiza en relación a la atención de las mujeres con complicaciones maternas graves.

OBJECTIVE The objective of this study is to contextualize adolescent pregnancy from milestones associated with the process of transition from youth to adulthood. METHODS This is a cross-sectional study conducted with 200 adolescents, users of the Brazilian Unified Health System. The sample size for the estimation of proportions has been calculated assuming a population ratio of 0.50 and 95% confidence level. The dependent variables – planned pregnancy, living with a partner, and having left the parents’ house – have been considered as markers of transition from dependence to independence, from youth to adulthood. In the analysis of the associated factors, we have used the Poisson model with robust variance. RESULTS Average age was 17.3 years, and most adolescents lived with a partner; approximately half of the adolescents got pregnant from their first partner and the average age of first sexual intercourse was 14.6 years. Only 19% of the adolescents were studying and most dropped out of school before the beginning of the pregnancy. In the bivariate and multiple analysis, we could see that the relationship with a partner for more than two years was associated with the three dependent variables. CONCLUSIONS The path of transition to adulthood has been the establishment of a link with a partner and consequent pregnancy, suggesting a clear pattern of male guardianship. The changing role of women in society observed in recent decades, which means choosing a professional career, defining the number of children, and choosing their partner(s), has not reached these young persons. RESUMO OBJETIVO Contextualizar a gestação em adolescentes a partir de marcos associados ao processo de transição da juventude para a vida adulta. MÉTODOS Estudo transversal realizado com 200 adolescentes usuárias do Sistema Único de Saúde. O tamanho da amostra para a estimação de proporções foi calculado considerando uma proporção populacional de 0,50, e nível de confiança de 95%. As variáveis dependentes – gestação planejada, morar com o parceiro e ter saído da casa dos pais – foram consideradas marcadores da transição da dependência para a independência, da juventude para a vida adulta. Na análise dos fatores associados, utilizou-se o modelo de Poisson com variância robusta. RESULTADOS A idade média foi 17,3 anos, a maioria coabitava com o companheiro; aproximadamente metade engravidou do primeiro parceiro e a idade média da primeira relação sexual foi 14,6 anos. Apenas 19% das jovens estudavam e o abandono escolar foi, na maior parte, anterior ao início da gestação. Nas análises bivariadas e na análise múltipla, observou-se que relacionar-se com o parceiro há mais de dois anos se associou às três variáveis dependentes. CONCLUSÕES O caminho de transição para a vida adulta foi o estabelecimento de um vínculo com um parceiro e consequente maternidade, sugerindo padrão claro de tutela masculina. A mudança do papel da mulher na sociedade observada nos últimas décadas, que implica optar por uma carreira profissional, definir número de filhos e escolher o(s) parceiro(s),não chegou a parcela dessas jovens.

Background The aim of this study was to determine whether PRENACEL (a bi-directional, mobile-phone based, short text message service (SMS)) increases the coverage of recommended antenatal care (ANC) practices. Methods A parallel, cluster-randomized trial in which 20 public primary Health Care Units (PHCUs) were randomly allocated to the intervention (10 PHCUs) or control (10 PHCUs) group. The study population included pregnant women aged 18 or above with a gestational age of 20 weeks or less. Pregnant women receiving ANC in intervention PHCUs were invited through leaflets and posters to register in PRENACEL. Women who registered in PRENACEL received a weekly set of short text messages with health education and health promotion content related to pregnancy and childbirth and were also able to clarify ANC queries through SMS. All women received routine ANC. The primary outcome was the proportion of women with high ANC Score, a composite measure of coverage of recommended ANC practices. Chi-square or Fisher’s exact tests and multivariate log-binomial regression were used to analyze the outcomes. Results A total of 1210 eligible women received ANC in the participating PHCUs and took part of this study (770 in the intervention group and 440 in the control group). 20.4% (157/770) of intervention-group women registered in PRENACEL, but only 116 read all messages (73.9% of women who registered in PRENACEL, 116/157). The adjusted intention-to-treat analysis suggested no difference between intervention and control groups in the primary outcome (Adjusted Relative Risk (AdjRR): 1.05 (95% Confidence Interval (CI): 1.00–1.09). Both crude and adjusted per-protocol analysis suggested a positive effect of PRENACEL (Crude RR (95% CI): 1.14 (1.06–1.22), AdjRR (95% CI): 1.12 (1.05–1.21). The multivariate analysis also suggests that the PRENACEL group (women who read all SMS) had higher mean ANC score [48.5 (±4.2) vs 45.2 (±8.7), p

The development of new treatments has improved survival and quality of life among cancer patients. Nurses are expected to answer questions and to provide orientation regarding patients' sexuality since it is an important aspect of life. The main objective of this paper is to understand the representations of sexuality among nurses working with women who survive breast cancer after diagnosis and during treatment assuming that their representations may affect communication with the patient. This is a qualitative study using an in-depth guideline which involved interviews with 28 nurses living and working in the southeast of Brazil. The narratives were submitted to a content analysis and categories of representations were identified and are discussed here. Several representations of sexuality were found in the nurses' discourses. Some of the nurses' representations may be expected to hinder their ability to provide helpful orientation regarding the sexual lives of these patients.

In this study we combined quantitative (questionnaire survey of 221 health care professionals [HCPs]) and qualitative (interviews with 14 doctors) methods to explore knowledge and attitudes toward health service assistance for women victims of intimate partner violence (IPV). Data were collected in Ribeirão Preto, Brazil, in 2007. We found that most HCPs presented good knowledge of definitions of gender violence, but they had low awareness of its local prevalence, sympathetic attitudes to such women, but highlighted a range of barriers to assisting them. We analyzed these findings in relation to sex, age, profession, and years of experience.

to describe the cases of violence against children reported in Ribeirão Preto-SP, Brazil.this was a descriptive study using data provided by the Violence and Accidents Surveillance System (VIVA), of the Municipal Health Department of Ribeirão Preto-SP, Brazil, from 2006 to 2008.a total of 498 cases of violence against children (0-9 years old) were reported in the period, with an increase in the number of notifications, from 112 in 2006 to 197 in 2008; 79.3% of the notifications came from the Health area; and most children were female (56.4%), aged between two and five years old (over 60%); most aggressors were male (53.6%) and the father figure stood out (22.7%); physical aggressions were the most frequent (59.2%) and the most frequent place of the occurrence was the family household (75.5%).most victims were female, abused by men, mostly fathers and other family members, at the family household.

NICHD NIH HHS World Health Organization ObjectiveTo generate a global reference for caesarean section (CS) rates at health facilities. DesignCross-sectional study. SettingHealth facilities from 43 countries. Population/SampleThirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10045875 women giving birth from 43 countries for model testing. MethodsWe hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. Main outcome measuresArea under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. ResultsAccording to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (). ConclusionsThis article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. Tweetable abstractThe C-Model provides a customized benchmark for caesarean section rates in health facilities and systems. Tweetable abstract The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems. Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Social Med, Av Bandeirantes, BR-3900 Ribeirao Preto, Brazil WHO, World Bank Special Programme Res Dev & Res Traini, UNDP UNFPA UNICEF WHO, Dept Reprod Hlth & Res, CH-1211 Geneva, Switzerland Univ Paris 05, Sorbonne Paris Cite, UMR 216, Inst Dev Res, Paris, France WHO Reg Off Amer, Women & Reprod Hlth CLAP WR, Latin Amer Ctr Perinatol, Montevideo, Uruguay Emory Univ, Rollins Sch Publ Hlth, Dept Epidemiol, Atlanta, GA 30322 USA Paris Descartes Univ, Ctr Epidemiol & Biostat, Obstetr Perinatal & Pediat Epidemiol Res Team, Inserm U1153, Paris, France Natl Inst Publ Hlth, Ctr Populat Hlth Res, Cuernavaca, Morelos, Mexico Univ Technol, Fac Hlth, Sydney, NSW, Australia Natl Ctr Child Hlth & Dev, Dept Hlth Policy, Tokyo, Japan Ctr Rosarino Estudios Perinat, Rosario, Argentina Lindsay Stewart R&D Ctr, Off Res & Clin Audit, Royal Coll Obstetricians & Gynaecologists, London, England London Sch Hyg & Trop Med, Dept Hlth Serv Res & Policy, London WC1, England Shanghai Jiao Tong Univ, Sch Med, Xinhua Hosp, Shanghai Key Lab Childrens Environ Hlth,Minist Ed, Shanghai 200030, Peoples R China Univ Estadual Campinas, Sch Med Sci, Dept Obstet & Gynaecol, Campinas, SP, Brazil Family Hlth Bur, Minist Hlth, Colombo, Sri Lanka Fiocruz MS, ENSP, BR-21045900 Rio De Janeiro, Brazil Natl Inst Hlth & Welf, Helsinki, Finland Univ Tokyo, Grad Sch Med, Dept Paediat, Tokyo, Japan Bayer Krankenhausgesellschaft, Bayer Arbeitsgemeinschaft Qualitatssicherun Stati, Munich, Germany Khon Kaen Univ, Fac Med, Dept Obstet & Gynecol, Khon, Kaen, Thailand Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Obstet & Gynaecol, BR-14049 Ribeirao Preto, Brazil Minist Sante, Direct Sante Famille, Ouagadougou, Burkina Faso Univ Washington, Inst Hlth Metr & Evaluat, Seattle, WA 98195 USA Univ Mongolia, Hlth Sci, Sch Publ Hlth, Ulaanbaatar, Mongol Peo Rep GLIDE Tech Cooperat & Res, Ribeirao Preto, SP, Brazil Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Paediat, BR-14049 Ribeirao Preto, SP, Brazil Univ Calif San Francisco, Dept Obstet & Gynaecol & Global Hlth Sci, San Francisco, CA 94143 USA Khon Kaen Univ, Fac Publ Hlth, Dept Biostat & Demog, Khon Kaen, Thailand Univ Fed Sao Paulo, Sch Med Sao Paulo, Dept Obstet, Sao Paulo, Brazil Inter Amer Dev Bank, Social Protect & Hlth Div, Mexico City, DF, Mexico Fortis Mem Res Inst, Gurgaon, Haryana, India Hosp Nacl Itaugua, Itaugua, Paraguay Univ Fed Sao Paulo, Sch Med Sao Paulo, Dept Obstet, Sao Paulo, Brazil NICHD NIH HHS: T32 HD052460 World Health Organization: 001 Web of Science

To validate the instrument Body Image Relationship Scale (BIRS) for Brazilian women with breast cancer.The instrument was administered by trained interviewers to 139 women who used the Brazilian Unified Health System (SUS). All of them had been submitted to cancer treatments between 2006 and 2010. The instrument was validated considering internal consistency and reliability. In order to compare the techniques, the same factorial analysis as used in the original paper was carried out.The Spearman-Brown correlation value was 0.8, indicating high internal reliability. The Cronbach's alpha found was 0.9, indicating a high level of internal consistency. Factorial analysis showed that four items had low factorial load and no discriminatory power, and another five items were relocated to other factors. When the instrument was applied, it showed variability to that of the original instrument.The Brazilian version of the Body Image Relationship Scale (BIRS), named Escala de Relacionamento e Imagem Corporal (ERIC), showed evidence of adequate reliability and internal consistency, making this instrument suitable to be recommended for application to Brazilian women with breast cancer, despite some limitations.

Forty percent of Brazilian married women from 15 to 49 years of age have undergone surgical sterilization. The 1988 Brazilian Constitution states that all scientifically proven contraceptive methods should be available to all citizens, but it was only in 1997 that specific family planning legislation was approved. This study examines physicians' perceptions and attitudes towards the current provision of female sterilization and its legal implications, as well as women's experience with obtaining and undergoing sterilization. The study design included: (1) an investigation of the hospitals and health professionals and (2) a survey of women sterilized in combination with cesarean delivery in 1998. The survey showed they had a median of 3 living children, 60.0% had been sterilized between 30 and 39 years of age, and 61.0% had paid for the procedure. Many women reported previous method failure and adverse effects with hormonal contraceptives. Women with less schooling and lower socioeconomic status had more children and had begun childbearing and had been sterilized at younger ages than women with more schooling and higher socioeconomic status. Inequalities related to reproduction were strongly associated with teenage pregnancy and inadequate knowledge about contraceptives. Quarenta por cento das mulheres brasileiras casadas de 15 a 49 anos de idade estão esterilizadas. A Constituição Brasileira de 1988 afirma que todos os métodos científicos de contracepção devam estar disponíveis para qualquer cidadão(ã), mas foi somente em 1997 que a regulamentação legal do planejamento familiar foi aprovada. Este estudo examinou as percepções e atitudes dos médicos em relação à oferta atual da esterilização feminina e suas implicações legais, e a experiência das mulheres em obter o procedimento. O desenho do estudo compreende: (1) uma investigação dos hospitais e profissionais de saúde e (2) uma pesquisa com mulheres esterilizadas durante parto cesariano em 1998. Elas tinham em média três filhos vivos, 60,0% foram esterilizadas entre 30 e 39 anos de idade, e 61,0% pagaram pela laqueadura. Muitas relataram falhas de métodos e efeitos adversos com o uso de contraceptivos hormonais. Mulheres de nível educacional e social mais baixo relataram maior paridade, começaram a ter filhos e foram esterilizadas mais jovens do que as mulheres com nível educacional e social mais alto. As desigualdades em torno da reprodução encontram-se fortemente associadas com gravidez na adolescência e baixo nível de conhecimento sobre métodos anticoncepcionais.

The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.L'Organisation mondiale de la Santé est en train de mettre au point la 11e révision de laLa Organización Mundial de la Salud está desarrollando la undécima revisión de laتقوم منظمة الصحة العالمية بوضع المراجعة الحادية عشرة للتصنيف الإحصائي الدولي للأمراض والمشكلات المتعلقة بالصحة (ICD-11)، المخطط نشرها عام 2017. وتم تكليف الفريق العامل المعني بتصنيف الاضطرابات الجنسية وجوانب الصحة الجنسية بمسؤولية مراجعة وإصدار التوصيات بشأن فئات الأمراض ذات الصلة بالميول الجنسية في الفصل المعني بالاضطرابات النفسية والسلوكية في المراجعة العاشرة (ICD-10)، التي تم نشرها عام 1990. ويشمل هذا الفصل فئات التشخيصات المستندة بشكل أساسي على التوجه الجنسي رغم إقرار المراجعة العاشرة للتصنيف الإحصائي الدولي للأمراض والمشكلات المتعلقة بالصحة بأن التوجه الجنسي وحده ليس اضطراباً. وتستعرض هذه المقالة البيّنات العلمية والأساس المنطقي السريري للاستمرار في إدراج هذه الفئات في التصنيف الإحصائي الدولي للأمراض. وتوصلت مراجعة البيّنات التي يتم نشرها منذ عام 1990 إلى وجود قدر ضئيل من الاهتمام العلمي بهذه الفئات. بالإضافة إلى ذلك، لم يجد الفريق العامل أي بيّنات تشير إلى أنها مفيدة سريرياً: لا تسهم في إيتاء الخدمات الصحية أو اختيار العلاج ولا توفر معلومات أساسية لترصد الصحة العمومية. علاوة على ذلك، من الممكن أن يتسبب استخدام هذه الفئات في أضرار غير لازمة عن طريق تأجيل التشخيص الدقيق والعلاج. ويوصي الفريق العامل بحذف هذه الفئات بالكامل من المراجعة الحادية عشرة للتصنيف الإحصائي الدولي للأمراض والمشكلات المتعلقة بالصحة. ويمكن التعامل مع مخاوف الصحة ذات الصلة بالتوجه الجنسي بشكل أفضل باستخدام فئات التصنيف الإحصائي الدولي للأمراض.世界卫生组织正在进行《疾病和有关健康问题的国际统计分类》(ICD-11)的第11次修订,修订版计划于2017年公布。性疾病和性卫生分类工作组负责审查1990年公布的第10次修订(ICD-10)中有关精神和行为障碍章节中与性相关的疾病分类,并提出建议。该章包括主要基于性取向的诊断类别,尽管ICD-10指出性取向本身并不是一种疾病。本文综述了继续在ICD包含这些类别的科学证据和临床理由。针对1990年以来的证据发表一篇综述几乎找不到这些类别有什么科学意义。此外,工作组也没有找到证据表明这些类别在临床上有用:既无益于健康服务交付或治疗选择,对公共卫生监测也没有提供重要信息。此外,使用这些类别可能因为推迟准确的诊断和治疗而产生不必要的伤害。工作组建议在ICD-11中完全删除这些类别。与性取向相关的健康问题可以使用其他ICD类别更好地解决。Всемирная организация здравоохранения разрабатывает 11-ю редакцию

The scope of this paper is to identify the experience, attitudes and impressions of health care professionals (HCPs) in addressing the needs of women patients suffering from intimate partner violence (IPV). In-depth interviews were conducted with 14 doctors and 11 nurses in Ribeirão Preto. Results show that there is an 'apparent invisibility' of IPV, the convenience of a tacit compact of silence about such violence on the part of women and HCPs. We studied the reasons given by HCPs for failing to deal with IPV. We also addressed the health service facility context, and the diversity of the professioinals' responses to violence, with indications of the emergence of a more proactive and positive stance. Qualitative data analysis highlights previous survey findings. A positive response from HCPs shows that there is perhaps some change from a narrow, medically-focused model of health care, to a more broadly defined social model. Objetivos: Identificar a experiência, as atitudes e os sentimentos dos profissionais de saúde (PS) quando abordam as necessidades de mulheres que sofrem violência do parceiro íntimo (VPI). Método: Foram realizadas entrevistas em profundidade com 14 médicos e 11 enfermeiras em Ribeirão Preto. Resultados: Há uma aparente invisibilidade e a conveniência de um acordo tácito de silêncio por parte da mulher e do PS; exploramos as razões dadas por eles para esta inabilidade em atender VPI. Também abordamos o contexto dos serviços de saúde, a diversidade de respostas dos profissionais e a emergência uma postura mais proativa e positiva. Discussão: A análise qualitativa realça os resultados de um inquérito prévio. Uma resposta positiva mostra que talvez haja algumas mudanças de perspectiva de um modelo medicalizado de cuidado à saúde para um modelo mais abrangente ou integral que define saúde como social.

This paper examines some problems involved in the provision of female sterilization procedures in Brazil, mainly those concerned with the ways in which this operation is offered. Female sterilization provision is analysed by reference to the broader institutional context and from the client's perspectives. These themes are discussed in the light of some recent survey findings. A survey was carried out between March and July, 1992 in two selected poor areas of Sa˜o Paulo Metropolitan Region. 3149 women were asked about contraceptive use including 407 sterilized women under 40 years old who were also interviewed about their adaptation to sterilization. Further information was also obtained through in-depth interviews with 15 sterilized women who regretted the operation. The findings highligh a complex network of interests and misunderstandings which shape the nature of choice of female sterilization by Brazilian low income women.

To understand the reproductive and sexual life of women treated for breast cancer.A total of 139 women with a diagnosis made at least 6 months ago were interviewed after being randomly selected in a rehabilitation service. The interviews were carried out between 2006 and 2010. The inclusion criteria were: to have used a rehabilitation service between 2006 and 2010, to be a Unified Health System user, to have been a patient at a regional hospital and to be resident in the area of DRS XIII-Ribeirão Preto, state of São Paulo. The interviewees were visited at home where a face to face questionnaire regarding sociodemographic features and questions about the disease and reproductive and sexual life was administered. For the last one, the Female Sexual Function Index instrument was used. Data were analyzed statistically by the χ² test, Fisher exact test, Student's t test, multivariate analysis by logistic regression, factorial analysis and the Cronbach's alpha.Most patients had between 2 to 3 children and 80% used some contraceptive. About half of them had had sexual intercourse in the last month, 45.3% had interrupted sexual intercourse during treatment and 25.9% did not. There were reports of decreasing sexual activity, although half of the interviewees had re-started sexual life during the first six months after treatment. About half presented sexual dissatisfaction. An active sexual life is associated with being younger than 40 years of age and to have a partner. No association was found between active sexual life and diagnosis and types of treatment.Sexual activity of women treated for breast cancer is not associated with the treatments, but with age and with the opportunity of having sex.

To estimate the prevalence of intimate partner violence against women and identify factors associated.Cross-sectional study comprising 504 women aged 15 to 49 years users of five primary care clinics in a municipality in the state of São Paulo, Southeastern Brazil, in 2008. Face-to-face interviews were carried out using a questionnaire consisting of 119 questions on sociodemographic information, reproductive health, perceptions of gender roles in the marital relationship and experience of violence. Univariate and multiple regression analyses were performed.More than a third of the women reported intimate partner violence. In the multiple regression analysis factors predisposing to violence included living in rental housing, sexual abuse during childhood, the partner's experience of physical violence during childhood, alcohol and drug use by the woman and her partner, and woman's perception of her partner's temperament.The factors identified produced a predictive model that can be used to assess a woman's risk of experiencing intimate partner violence.

To evaluate the satisfaction with the surgical sterilization performed by Unified Health System (SUS) and to detect factors that can influence the choice between tubal ligation and vasectomy.A total of 235 women and 78 men who were sterilized in a five years time period were interviewed. The studied variables included their socio-demographic features, their reason for sterilization, their opinion on the access to the surgery, the counseling, hospital services and the satisfaction with the procedure.Most were married or lived together, had an average of 3.4 living children and a mean of 6.7 years of schooling. They declared that the average monthly per capita income was R$ 212.81. The most of them belonged to the social status C. They were white and Catholics. The most of them found easy to obtain the surgery and the waiting time was appropriate. They become satisfied with the counseling and 99% were satisfied with sterilization. However, one fourth, incorrectly, found that sterilization was easy to reverse. A study on the couples showed important differences on choosing vasectomy or tubal ligation.The results show that it is necessary for improvement in the information provided to the candidates to sterilization. Although they are satisfied now, they could not be in the future. The evaluation from the perspective of the health service user should take into account not only their opinion, but also their interests.

Women experience a major process of reshaping their body image when they deal with breast cancer. This article seeks to understand the relationship that breast cancer and its treatment have in the process of (re)construction of a woman's body image. The ultimate objective is to promote knowledge to train health professionals to become more aware of a woman's quality of life. A systematic review of the literature of scientific articles published between 2004 and 2009 available in three scientific databases was conducted and a total of 56 articles were reviewed and grouped into four thematic categories. There is a pressing need for further studies on the socio-cultural characteristics of women with breast cancer, the differences of (re)construction of body image of young and older women, and Brazilian publications about the personal experience and socio-cultural context of women with breast cancer.

This study aimed to evaluate the construct validity of a version of the Female Sexual Function Index (FSFI). The version was inserted into a multidimensional questionnaire and applied face-to-face to 235 sterilized women. Non-response rate was 1.7%. The sample proved to be highly homogeneous, with low income and education. Cronbach's alpha of 0.948 indicated high internal consistency. Factor analysis showed that the instrument was measuring four factors: desire/arousal, lubrication, orgasm/satisfaction, and pain. This may reflect characteristics of the instrument itself, female sexual response, or even the sample's cultural peculiarities, which can affect understanding of the questions or concepts with which the instrument deals. This study emphasizes the need for further research in the general population to determine the psychometric properties of the FSFI, such as its factor composition and definition of appropriate cut-off points for the Brazilian population.

To characterize the profile of individuals who were unable to obtain the surgical contraception procedure, and associated factors.This was a cross-sectional study conducted in Ribeirão Preto (Southeastern Brazil) in 2004, on 230 individuals who were unable to obtain sterilization surgery through the National Health System between 1999 and 2004. A questionnaire on sociodemographic information, use of contraceptive methods, aspects of sterilization and desire to undergo sterilization in the future was applied. The variables of sex, age, religion, per capita income, marital status and schooling level were compared between the total number of individuals who were unable to obtain this procedure and 297 individuals who were sterilized.Among the 230 interviewees, 21.3% were men and 78.7% were women. Most of them were married, white and Catholic and had had at least four years of schooling. The median monthly per capita income was R$ 140.00. Twenty-three of them (10%) had hopes of undergoing the operation. The remaining 207 were classified in two groups: 71% had decided to postpone the operation and 29% had faced obstacles in relation to gaining access to sterilization. The latter group was associated with being female, young and black. After logistic regression, being black was the only factor that remained associated with inability to obtain sterilization. Comparison with individuals who were able to obtain the procedure showed that being female, older, evangelical and single were associated with inability to obtain sterilization, while higher income and schooling levels favored access.Few of the individuals studied had not had access to sterilization. Most had postponed the procedure and a smaller proportion had encountered institutional obstacles. Blacks encountered more barriers than whites did.

This article presents the results of a study in the city of São Paulo, Brazil, aimed at estimating the frequency of induced abortion among women 15 to 49 years of age. The objective was to characterize the occurrence of induced abortion by comparing the ideal number of children, age, and contraceptive use between married and single women. Based on random sampling, 1,749 interviews were held, including 764 married women, 658 single women, and 327 with other marital status. The analysis included: mean number of abortions per woman by analysis of variance and proportions of abortions and pregnancy, using the chi-square test. The mean abortion rate for married women (45 per thousand) did not differ statistically from that of single women. However, the pregnancy rate was much lower in single women, and when single women became pregnant they used abortion more frequently; while fewer than 2% of pregnancies in married women ended in induced abortions, among single women the abortion rate exceeded 18%. Therefore, the priority in the reproductive health field should be to invest in the supply and dissemination of appropriate contraceptive methods for women's early sexually active life. Apresenta-se uma pesquisa realizada na cidade de São Paulo, Brasil, para dimensionar o aborto provocado entre mulheres de 15 a 49 anos. O objetivo é caracterizar a ocorrência do aborto provocado analisando o número ideal de filhos, idade e uso de contraceptivos comparando-se as casadas e solteiras. Mediante sorteio aleatório foram realizadas 1.749 entrevistas, sendo 764 com mulheres casadas, 658 com solteiras e 327 de outras categorias maritais. A análise inclui: a média de abortos por mulher, por meio de análise de variância e proporções de aborto e de gestação, usando-se o teste do qui-quadrado. Verificou-se que a média de abortos, 45 por mil, por mulheres casadas não difere da das solteiras. No entanto, as solteiras engravidam numa escala muito menor e, ao engravidarem, recorrem mais largamente ao aborto provocado - enquanto que menos de 2% das gestações das casadas resultam em aborto provocado, entre aquelas esta cifra supera 18%. A prioridade na área de saúde reprodutiva, sem dúvida, deve ser investir na oferta e divulgação de métodos contraceptivos adequados ao início da vida sexual.

This study examined female adolescents' knowledge concerning STDs and transmission, condom use, and health care. It was a cross-sectional study of 90 adolescents living in an area covered by the Family Health Program in Ribeirão Preto, São Paulo, Brazil. Data were collected through household interviews using a structured questionnaire, followed by preliminary analysis of simple frequency of variables. Most adolescents were single, sexually active, and with limited knowledge concerning STDs. Condoms were known as the main means of prevention, but only 35.2% of the sample reported always using them. There was a large drop in condom use (from 71.1% to 37.1%) when comparing the first versus the most recent sexual intercourse. Teenagers did not consider themselves at risk of STDs (65.5%), although 57.8% reported related symptoms and 36.7% had never undergone gynecological examination. The results point to the need for special attention to adolescent health care. The lack of effective protection makes them vulnerable to STDs, including HIV/AIDS, even though they do not consider themselves at risk.

The epidemiology of female sexual dysfunctions is still not well known. The Female Sexual Function Index (FSFI) is a short questionnaire specially designed to assess female sexual response. This study aimed to evaluate the cross-cultural equivalence of the Portuguese version of the FSFI. The cross-cultural adaptation involved five steps: translation, back-translation, formal equivalence assessment, review by specialists in sexuality, and pre-testing. After identification of semantic problems, agreements, and disagreements, a brief version was proposed, selecting and incorporating items from one of the two Portuguese versions. Some changes were made after pre-testing the questionnaire, most of which to make the Portuguese version more readily comprehensible and acceptable for the target population, using ordinary words as options or to complement the scientific language. Comparing more than one version of the instrument in the process of cross-cultural equivalence allowed detecting problems and difficulties in adapting the language, which would not have been observed otherwise.

In 1999 the Municipal Health Department in Ribeirão Preto, São Paulo, Brazil, implemented the provision of surgical contraceptive methods according to prevailing legal requirements. This study aimed to characterize the candidates for surgical sterilization and study the variables associated with the type of procedure. A total of 95 candidate patient records were studied, and statistical logistic regression analysis and Fisher's exact test were performed considering a significance level of ? = 0.05. Most candidates had stable partners, low schooling, and low income, were satisfied with their number of children, and had already tried to limit the number of children using reversible contraceptives. Mean age was 34.2 years, 45.3% underwent female sterilization, 35.8% underwent vasectomy, and 18.9% did not submit to any procedure. The odds of a man older than 35 having a vasectomy were 6.1 times that of a younger man (OR = 6.1; 95%CI: 2.4-16.4). More married men submitted to vasectomy than men who cohabited (OR = 4.0; 95%CI: 1.5-12.4). Women with four or more children were more likely to undergo sterilization than those with fewer children (OR = 3.1; 95%CI: 1.1-8.5).

Intimate partner abuse is a complex phenomenon and a public health problem and health care services are one of the places sought by women in this situation. The objective of this study was to assess the prevalence of violence against women attending a health care center.This study was carried out in a municipality of Southeastern Brazil, in 2003. A sample of 265 women, aged 18 to 49 years old, was interviewed using a questionnaire administered face-to-face. Violence was classified as psychological, physical, sexual and general. Statistical analyses utilized were exact logistic regression and Fisher's exact test.Psychological violence, at least once in life, was reported by 41.5%, physical violence by 26.4%, and 9.8% reported sexual violence. "General violence", which refers to anyone of the above mentioned types of violence, was reported by 45.3% of the women, and, in 20.3% of the cases, they stated it had occurred during the last 12 months before the interview. However, when asked whether they had suffered any kind of violence in life, only 22.3% answered affirmatively. The multivariate analysis indicated that the risk factors for each type of violence were: drug use by the partner, socioeconomic status and family history of violence for both psychological and general violence; drug use by the partner, schooling and family history of violence for physical violence; and, socioeconomic status and family history of violence for sexual violence.This study indicates that the prevalence of violence among women attending the health center is high and consistent with the results of other investigations. It also suggests that most of the violence is invisible to the health center.

This study focused on the knowledge and opinions of physicians regarding legal and ethical aspects of abortion. A self-administered questionnaire was filled out by 57 physicians working in the emergency rooms of two hospitals in Ribeirão Preto, São Paulo State, Brazil in 2001. The questionnaire had 38 questions on general knowledge, legislation, and attitudes towards abortion. Interviewees' mean age was 28.3, most were females, 52.6% were single, 42.1% were married, 54.4% were Catholic, and 21% were Spiritists. Although most of the physicians had a good level of overall knowledge on abortion (70%), one in five was not aware that abortion is the main cause of maternal mortality in Brazil. Most accepted the prevailing legal conditions for performing an abortion in Brazil but would also include fetal malformation incompatible with life, while opposing decriminalization of abortion on other grounds. Limited knowledge is revealed by misconceptions concerning enforcement of the prevailing legislation in practice. The study strongly suggests that many physicians lack knowledge or face difficulties in conforming to the Brazilian legislation on abortion.

To characterize the profile of pharmacists employed as technical supervisors in drugstores and evaluate their knowledge regarding certain aspects of the legislation controlling drugstores and the profession in general.Based on 175 drugstores in the city of Ribeirão Preto, southeastern Brazil, 100 pharmacists/technical supervisors were randomly selected. Data collection was done by means of in-person interviews, and was guided by a questionnaire evaluating knowledge and attitudes. Data were processed and analyzed using Epi Info and Stata software. Associations were sought between dependent and independent variables using Pearson's chi-squared and Fisher's exact tests.Most pharmacists were women (64%), aged 22-29 years (47%), graduated approximately three years prior to data collection, trained to work in the pharmaceutical industry (36%) or in clinical analysis (29%). Pharmacist's knowledge of sanitary legislation was considered as insufficient for 28% of subjects, regular for 50%, and good for 22%. Low levels of knowledge were observed regarding the legal requirement for the presence of a pharmacist during the entire drugstore opening hours, pharmacists' attributions, sale of antibiotics, and penicillin administration. It was found that most professionals have difficulties handling the concepts of 'generic' and 'similar' drugs. Low level of knowledge was not associated with any of the independent variables, indicating that this is a generalized phenomenon, i.e., one present among pharmacists of all age groups and both sexes, irrespective of the time since graduation, institution attended, and modality of graduation, among others.We conclude that training in the field of drug pharmaceutical care, during undergraduate studies and, especially, during traineeship in pharmacies and drugstores is deficient. It is necessary to divulge information concerning sanitary legislation so that pharmacists may fully exert their profession, without risk of legal threats or hazard to the population.

OBJECTIVES: To study HIV-positive women and women at risk of becoming infected with HIV who attended HIV prevention education group sessions at a university hospital in Bra-zil and to compare the use of the female condom and the male condom by these two groups of women. METHODS: The study subjects were 165 women participating in HIV prevention education group sessions at the Medical School Hospital of Ribeirao Preto of the University of Sao Paulo, in the city of Ribeirao Preto, Sao Paulo, Brazil. Women could be enrolled in the study from August 2000 to June 2001, and the follow-up observation time period was from August 2000 to July 2001. Male condoms and female condoms were freely distributed to all the participants at the end of each educational session and also at the end of each follow-up visit that the participants made. Each woman took part in an initial interview and was asked to return monthly. At each follow-up visit an additional short interview was carried out in order to investigate use of the male condom and of the female condom. Variables that were examined for the study included age, education, ethnic group, marital or relationship status, number of children, the women's use of male condoms and female condoms, commercial sex (whether the women had ever had sex in exchange for money, gifts, or favors), and previous knowledge of the female condom. RESULTS: The 165 women studied fell into the following three categories: 132 of them (80.0%) were HIV-positive, 26 of them (15.8%) had a sexually transmitted disease (STD) other than HIV and did not have an HIV-positive partner, and 7 of them (4.2%) had an HIV-positive partner but did not have HIV or any other STD. The women ranged in age from 15 to 64 years, with a mean of 30.3 years. Of the women in the study, 69.7% of them were married or were cohabitating, and 90.9% of them had a sexual partner. Just over two-thirds of the women had seven years of formal schooling or less. Out of 163 women, a total of 31 of them (19.0%) had never used the male condom with a partner, and 49 of the 163 (30.1%) had not used a male condom at the time of the last sexual intercourse. Out of the 165 women, 74 of them (44.8%) returned for at least one follow-up visit. Of these 74 women, 58 of them (78.3%) reported using the female condom between the initial interview and the first follow-up visit. The majority of the 74 women who returned for a visit liked using the female condom, and the women reported that their partners also generally accepted the female condom. In comparison to women at risk of HIV, HIV-positive women were more likely to have used the male condom with a partner before the initial interview. Women who continued returning over a longer follow-up period were more likely to have used the female condom at the time of the last sexual intercourse. No association was found between female condom use at the time of last sexual intercourse and the woman's HIV infection status. CONCLUSIONS: In comparison to the women at risk of HIV, the HIV-positive women in our study were more likely to use male condoms with their partners, to return for follow-up visits, and to have a longer follow-up period. The acceptance of the female condom among the HIV-positive women in this study, as reported at their first follow-up visit, appears to be similar to the acceptance of the female condom among women in general in Brazil.

To analyze data on contraceptive use in the State of São Paulo, Brazil, collected by the Demographic and Health Survey (DHS) conducted in 1996.The study data were compared to 1986 DHS and 1996 data on the Brazilian population. Contraceptive use among married or cohabiting women was evaluated focusing on age, number of children, schooling, and age and timing of female sterilization. Statistical analysis was performed using Student t-test and Kendall's non-parametric test.Unlike data on the Brazilian population, female sterilization rates were steady in the State of São Paulo during the studied period. The same contraceptive pattern is seen in both Brazil and São Paulo: women aged up to 30 years use largely pills; female sterilization predominates in women over 30, increasing with the number of children and decreasing with years of schooling. Male methods have also increased in recent years, being greater in São Paulo than in Brazil. São Paulo also shows a greater variety of reversible contraceptive methods.Although there were some differences, the prevalence of only two contraceptive methods in both Brazil and São Paulo suggests a tendency regarding the contraceptive methods offered and in reproductive health in the view of new regulations on family planning.

This paper analyzes the attitudes of low-income women towards abortion and contraception. A survey was conducted in 1992 with a total of 3,149 childbearing-age women living on the outskirts of the Greater Metropolitan São Paulo Area. The study focuses on a sub-sample of 583 women. Attitudes of sterilized and non-sterilized women are compared. Women, especially those sterilized, found the most important attribute of a contraceptive method to be its effectiveness. Women currently taking the pill were less likely than those sterilized to agree that sterilization was the best method because of its effectiveness. Sterilized women were less likely than non-sterilized women to trust the pill. Sterilized women were more likely than non-sterilized to have reported adverse effects from the pill. Most women found abortion unacceptable except in the case of risk to the woman's life. Women using more effective methods showed stronger negative attitudes towards abortion. The tendency to be sterilized while still young was associated with more negative attitudes towards abortion. Family planning activities in basic health care services should include individual counseling for contraceptive use.